But persistence shows EHR warnings are not always enough in cath lab

Action Points

Note that this analysis of Veterans Affairs data found a low, but non-zero rate of contraindicated antiplatelet therapy use in the setting of cardiac catheterization.

Broadly, the use of contraindicated antiplatelet agents was not associated with an increased risk of mortality, after adjustment for other risk factors.

The use of certain contraindicated antithrombotics during and after percutaneous coronary intervention (PCI) is uncommon but still a problem, a large VA registry study showed.

Overall, just 1.1% of the 64,294 patients in the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program who had PCI performed from 2007 to 2013 received contraindicated antiplatelet medication.

Yet among patients with a contraindication to an antiplatelet agent, 6.5% did ultimately receive one, Geoffrey D. Barnes, MD, MSc, of University of Michigan Frankel Cardiovascular Center in Ann Arbor, and colleagues reported online in Circulation: Cardiovascular Quality and Outcomes.

"Although the overall rate of contraindicated medication use among patients with PCI is low (1.1%), this study highlights the problem of medication errors in the U.S. Importantly, these data illustrate that the use of contraindicated antiplatelet medications persists, despite high-profile reports and electronic medical record [EMR] built-in warnings," the authors noted.

"The observation that the use of contraindicated medications was not significantly associated with risk-adjusted mortality does not diminish the prognostic significance of the findings of this study," Dominick J. Angiolillo, MD, PhD, of University of Florida College of Medicine in Jacksonville, told MedPage Today.

Although bailout situations in ST-segment elevation myocardial infarction care may call for the use of contraindicated medication, bailouts explained only 13% of such cases reported, the investigators noted.

As for why antiplatelets continue to be used in patients with contraindications, Barnes and colleagues noted the urgency of some PCI procedures: "antiplatelet medications are often administered before they are entered into the medical chart in response to verbal orders given during the procedure, potentially limiting the ability for an EMR-triggered alert to prevent the use in patients with a known contraindication. Many procedures are performed urgently with limited opportunity to review patient data (with the patient or the EMR) at the time of critical medication decisions."

"Not all providers may be aware of the FDA package label contraindications, or they may not agree with the label restrictions," they added.

"Physician-nurse communication is a uniquely important opportunity to reduce contraindicated medication use in the cardiac catheterization laboratory given the frequency of verbal orders. Empowering nurses or other care-team providers to identify potential medication contraindications and bring those to the physician's attention is integral to safe patient-care delivery," according to Barnes' group.

Included in any cardiac catheterization laboratory quality-improvement activities, they added, should be "educational efforts targeting physician and care-team knowledge about the potential medication contraindications."

The drugs with the most contraindicated usage were eptifibatide (Integrilin, 13.7%) and abciximab (ReoPro, 4.6%).

There was no association between contraindicated abciximab use and 30-day mortality, either. However, it was tied to increased bleeding in patients with thrombocytopenia (25.9% versus 12.1% for those without, HR 2.23, 95% CI 1.58-3.16) and those with a previous stroke (15.2% versus 7.9%, HR 1.93, 95% CI 1.37-2.71).

"The point estimates clearly suggested harm," Angiolillo, who was not involved in the study, noted. "Moreover, this data set and analysis was not specifically designed to demonstrate mortality, which is a very hard endpoint. I think that the association with other endpoints, such as bleeding, known to be associated with worse short- and long-term outcomes, including mortality, underscores that the use of contraindicated medications is dangerous."

Barnes' analysis underscored that, in real-world practice, use of contraindicated medications remains a problem and that there is still room for much improvement, Angiolillo continued.

Given that the data were derived from Veterans Affairs centers, the authors acknowledged that their results may not be generalizable to other PCI centers. The lack of full pharmacy data may have also led to a possible underestimation of contraindicated antithrombotic usage, they noted.

Barnes disclosed consulting for Portola and receiving research support from BMS/Pfizer and Blue Cross Blue Shield of Michigan.